Application for Renewal Of Registration   with the
Maharashtra Medical Council, Mumbai
Application No :  MMC201919689 Date : 07/05/2019
To,
Registrar ,
Maharashtra Medical Council ,
189/A, Anand Complex, 2nd Floor,
Sane Guruji Marg, Arthur Road Naka,
Chinchpokali (W), Mumbai - 400 011.
 
Sub: Dr  (Smt/Shri)  BAPAT SIDDHESH VISHWANATH
Registration No:  2009052354   Registration Date : 21/05/2009   Valid upto Date :21/05/2029
Sir,
I the undersigned applicant, request yoy that my name may be continued on the Register of Medical Practitioners maintained by the Maharashtra Medical Council as per 23 (a)/23 (c) of MMC Act 1965 and amendment 2003. My particulars are as Follows :
Name of Applicant : Mr. BAPAT SIDDHESH VISHWANATH
Name of Father : Mr. BAPAT VISHWANATH YASHWANT
Name of Mother : Mrs. BAPAT MEGHANA VISHWANATH
In Case of Married Women
Maiden Name : -

RESEDENTIAL ADDRESS : F2/1103, VIJAYNAGAR SOCIETY, SAHAR ROAD, ANDHERI EAST,
City : MUMBAI (SUBURBAN) District : MUMBAI (SUBURBAN)
State : MAHARASHTRA Country : INDIA
Pincode : 400069
Date of birth : 05/10/1985 Tel No (Res) : Clinic No :
Mobile No : 9930925424 Email Id : drsiddheshretina@gmail.com  
Total Obtained Credits Points : 30
Remaining Credits Points : 0
Qualification Details
 Details of QualificationName of CollegeUniversityPassing YearCertificate NoCertificate Date
1.M.B.B.S.GSMC MUMBAIMAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK2009  
2.M.S. (Ophthalmology)GMC,RAJKOTSAURASHTRA UNIVERSITY, GUJARAT20122037/201228/06/2012
Pariticulars Of Payment
Payment Mode : Online Payment
Receipt No : 201912703374382
Receipt Date : 08/05/2019
   I have uploaded following documents:
1.Latest Passport size Photograph
2.Photocopy Of Additional Qualification certificate of MMC
3.Self attested photocopy of MMC Registration Certificate
4.Original Undertaking
5.Self attested photocopy of Aadhar Card
DECLARATION (Registered Medical Practitioner)
I shall abide by the Code of medical Ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
Date : 07/05/2019
    Applicant signature               


NOTE:- You do not need to submit the print out of original submitted Renewal Application form to MMC office.